Remote Filling Verification - Click on 2 Different Errors
5411770
12/8/20XX
Jim Miller
Harold Green
Take 1/2 tablet by mouth twice a day for PTSD.
Lorazepam 0.5 mg Tablet
30
0
12/8/20XX
Geneva
1 Year
RPh
Pharmacy Software System
Insurance Information
Rx Origin Code: 1
Pharmacy DAW Code:
Drug NDC: 00904-5980-61
Quantity: 30
Days Supply: 30
AWP Cost/Unit: $0.71
Total Drug Cost: $21.30
Dispensing Fee: $2.00
Total Billed: $23.30
Payer Code: 3-PARTY
Insurance Information
Rx Origin Code: 1
Pharmacy DAW Code:
Drug NDC: 00904-5980-61
Quantity: 30
Days Supply: 30
AWP Cost/Unit: $0.71
Total Drug Cost: $21.30
Dispensing Fee: $2.00
Total Billed: $23.30
Payer Code: 3-PARTY
Pharmacy Software System
Rx Documentation
Rx Number: 5411770
Dispensing Date: 12/8/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 12/8/20XX
Initials: RPh
Drug Manu: Geneva
Rx Documentation
Dispensing Date: 12/8/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 12/8/20XX
Initials: RPh
Drug Manu: Geneva
